Lisa M. Foglia

Objective structured assessment of technical skills for episiotomy repair

OBJECTIVE This study was undertaken to estimate the reliability and validity of an objective structured assessment of technical skills (OSATS) for midline episiotomy repair using a lifelike anatomic model. STUDY DESIGN Eighteen residents were administered an episiotomy OSATS. Two evaluators independently completed an objective score sheet assessing six key components of the repair, seven global surgical skills, and a pass/fail score for each resident. Residents also completed an anonymous self-assessment. RESULTS Reliability indices were 0.95 for the checklist and global surgical skills rating. Construct validity found significant differences on the checklist, global surgical skills, and pass/fail score sheets by residency level. Residents more often assessed their own global surgical skills performance lower than the independent evaluators. Surprisingly, 61% (11/18) of the residents failed the assessment, including all postgraduate year 1 and postgraduate year 2 residents. CONCLUSION Episiotomy OSATS that used task-specific and global checklists provide a reliable and valid method of assessing resident skills in this anatomic model, and performance correlates with resident year level of training.

Collaborative Practice Model: Madigan Army Medical Center

In 2007, Madigan Army Medical Center implemented a new maternity care delivery model, integrating obstetricians and certified nurse-midwives (CNMs) in a collaborative practice. The change was driven by multiple factors, including patient preference, changes in the resident workweek, and low provider satisfaction. This article describes the elements of successful collaboration, including the structure, effective teamwork principles, role of the CNM in resident education, and preliminary data on mode of delivery, the number of CNM-supervised resident births, and procedures, such as episiotomy and epidural use.

Noninvasive prenatal testing: limitations and unanswered questions

The clinical use of noninvasive prenatal testing to screen high-risk patients for fetal aneuploidy is becoming increasingly common. Initial studies have demonstrated high sensitivity and specificity, and there is hope that these tests will result in a reduction of invasive diagnostic procedures as well as their associated risks. Guidelines on the use of this testing in clinical practice have been published; however, data on actual test performance in a clinical setting are lacking, and there are no guidelines on quality control and assurance. The different noninvasive prenatal tests employ complex methodologies, which may be challenging for health-care providers to understand and utilize in counseling patients, particularly as the field continues to evolve. How these new tests should be integrated into current screening programs and their effect on health-care costs remain uncertain.Genet Med 2014:16(4):281–285.

Effects of deployment on depression screening scores in pregnancy at an army military treatment facility.

OBJECTIVE: To estimate the relationship of positive screening for depression during and after pregnancy with deployment status of the spouse. METHODS: We conducted a retrospective cohort study by reviewing a departmental database of women who completed the Edinburgh Postpartum Depression Scale during pregnancy from 2007 to 2009. Per departmental protocol, screening is offered at the initial obstetric visit, at 28 weeks of gestation, and at 6 weeks postpartum. A score of 14 or higher was considered high risk for having depression, and referral for additional evaluation was recommended. Included in our survey was an additional question that asked if the patients spouse was currently deployed, returning from deployment, preparing to deploy, or if no deployment was planned. All data were entered into an electronic database and statistical analysis performed comparing Edinburgh Postpartum Depression Scale scores at each time period and deployment status. RESULTS: A total of 3,956 surveys were complete and available for analysis. The risk of a positive screen was more than doubled compared with the control group (no deployment planned) if the spouse was deployed during the 28–32 week visit (4.3% compared with 13.1%, P=.012) or the postpartum period (8.1% compared with 16.2%, P=.006). CONCLUSION: Deployment status has a measurable effect on the prevalence of elevated depression screening scores during pregnancy and in the postpartum period. These findings suggest that more intense monitoring, assessment, and treatment may be warranted for this at-risk population. LEVEL OF EVIDENCE: II

Elective Induction of Labor Compared With Expectant Management of Nulliparous Women at 39 Weeks of Gestation: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether the elective induction of labor in nulliparous women with an unfavorable cervix affects the cesarean delivery rate. METHODS: We conducted a randomized controlled trial at a tertiary care medical center. Nulliparous woman between 38 0/7 and 38 6/7 weeks of gestation who were least 18 years of age with a singleton gestation and a Bishop score of 5 or less were randomized to elective induction of labor or expectant management. The induction of labor group was induced within 1 week of enrollment but not before 39 0/7 weeks of gestation. The control group continued routine prenatal care with admission for labor or obstetric indication. The primary outcome was cesarean delivery. Assuming a 20% rate in women in a control group, 80% power, and a goal to detect a twofold increase to 40% in the induction of labor group, 162 patients were needed. RESULTS: From March 2010 to February 2014, 82 patients were randomly allocated to induction of labor and 80 to expectant management. Baseline characteristics were similar between groups. The cesarean delivery rate in the induction of labor group was 30.5% (25/82) compared with 17.7% (14/79) in the expectant management group (relative risk 1.72, 95% confidence interval 0.96–3.06). CONCLUSION: In nulliparous women with a Bishop score of 5 or less, elective induction after 39 0/7 weeks of gestation compared with expectant management of pregnancy did not double the rate of cesarean delivery. CLINICAL TRIAL REGISTRACTION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01076062. LEVEL OF EVIDENCE: I

Improving knowledge about prenatal screening options: can group education make a difference?

Abstract Objective: To determine if the addition of group education regarding maternal serum screening and diagnostic testing for aneuploidy and neural tube defects improves patient knowledge and affects the uptake of testing compared to individual education alone. Method: We conducted a prospective study of 443 obstetric patients to assess knowledge of prenatal testing options based on individual provider counseling (n = 331) or provider counseling with supplemental group education (n = 112). We used a chi-square test to compare the number of correct survey answers between the two groups. Results: There was no difference in baseline knowledge. Patients receiving group education showed a statistically significant improvement in knowledge. After initiation of group education, the uptake of maternal serum screening declined while the uptake of amniocentesis remained unchanged. Conclusion: Group education in addition to individual counseling to discuss prenatal testing options appears to be effective in improving knowledge compared to individual provider counseling alone. Improved knowledge may affect uptake of prenatal screening tests due to more informed decision making.

Idiopathic polyhydramnios: persistence across gestation and impact on pregnancy outcomes

PURPOSE To investigate the likelihood of resolution of idiopathic polyhydramnios in pregnant women and compare outcomes between resolved and persistent cases. METHODS One hundred and sixty-three women with idiopathic polyhydramnios who delivered at two medical centers during a 3 year period (January 2012-January 2015) were included in the study. Exclusion criteria included congenital fetal anomalies, maternal diabetes, isoimmunization, fetal infection, placental tumors or anomalies, and multiple gestation. Polyhydramnios was defined as SDP≥8cm or AFI≥24cm. Resolved cases were defined as those with AFI and/or SDP falling and remaining below 24cm and 8cm respectively. Pregnancy outcomes were compared between resolved and persistent cases. Two-sample t-test or Wilcoxon rank-sum test was used for continuous variables while chi-square test or Fishers exact test was used for categorical measures. RESULTS Resolution was noted in 61 of 163 (37%) patients. There were no differences in maternal age, gravidity or parity between resolved and persistent cases. Mean gestational age at diagnosis of polyhydramnios and overall mean AFI were significantly lower in the cases that resolved (29.7±4.5 weeks vs 33.4±4.1 weeks, p<0.0001; 23.3±3.5cm vs 25.8 23.3±4.0cm, p=0.0002). Similar to AFI measurements, mean SDP was also lower in cases with resolution (p=0.002). There was no difference in induction rates, mode of delivery, amnioinfusion rates, meconium staining of amniotic fluid and fetal heart rate abnormalities influencing intrapartum management between the two groups. Induction of labor for fetal indication and rupture of membranes were significantly more common in the persistent group. Cesarean delivery for abnormal lie and fetal distress did not differ between the groups. There was an increased risk of macrosomia (>4000g) and preterm delivery (<37 weeks) in the persistent group (p<0.05). CONCLUSIONS Resolution rate was approximately 37% and more likely in cases diagnosed earlier in pregnancy and with lower mean amniotic fluid volume. Preterm delivery and macrosomia were more common in cases that persisted across gestation.

Elective Induction of Nulliparous Labor at 39 Weeks of Gestation: A Randomized Clinical Trial

INTRODUCTION: Elective induction of labor is common despite the paucity of prospective data on maternal and neonatal outcomes. The objective of this study was to investigate the effect of induction of labor, at 39 weeks of gestation, on the frequency of cesarean delivery in nulliparous women with an unfavorable cervix compared with expectant management. METHODS: Nulliparous women aged 18–40 years with an uncomplicated pregnancy and a Bishop score of 5 or less receiving care at single medical center were assigned to induction of labor at 39 weeks of gestation or to expectant management in a parallel group randomized clinical trial. Maternal and neonatal outcome data were analyzed for 156 women. RESULTS: Cesarean delivery occurred in 24 of 78 (30.7%) patients in the induction of labor group and in 14 of 78 (18%) patients in the expectant management group (relative risk 1.7, 95% confidence interval 0.96–3.06, P=.07). Time from admission to delivery was longer in the induction of labor group. Meconium-stained amniotic fluid occurred more often in the expectant management group. There were no differences observed in the frequency of other outcomes. CONCLUSIONS: Cesarean deliveries in nulliparous women with an unfavorable cervix were not increased in those electively induced at 39 weeks of gestation compared with those expectantly managed. Further investigation into the clinical use of elective induction is warranted in larger multicenter trials. Based on this study, concern over maternal and neonatal outcomes including mode of delivery should not be perceived as stumbling blocks to further study of this commonly used yet understudied intervention.

Maternal pulse pressure at admission is a risk factor for fetal heart rate changes after initial dosing of a labor epidural: a retrospective cohort study

OBJECTIVE To examine low maternal admission pulse pressure (PP) as a risk factor for new onset postepidural fetal heart rate (FHR) abnormalities. STUDY DESIGN Retrospective cohort study of nulliparous, singleton, vertex-presenting women admitted to labor and delivery after 37 0/7 weeks that received an epidural during labor. Women with a low admission PP were compared with those with a normal admission PP. The primary outcome was new onset FHR abnormalities defined as recurrent late or prolonged FHR decelerations in the first hour after initial dosing of a labor epidural. RESULTS New onset FHR abnormalities, defined as recurrent late decelerations and/or prolonged decelerations, occurred in 6% of subjects in the normal PP cohort compared with 27% in the low PP cohort (odds ratio, 5.6; 95% confidence interval, 2.1-14.3; P < .001). A multivariate logistic regression analysis generated an adjusted odds ratio of 28.9 (95% confidence interval, 3.7-221.4; P < .001). CONCLUSION New onset FHR abnormalities after initial labor epidural dosing occur more frequently in women with a low admission PP than those with a normal admission pulse. Admission PP appears to be a novel predictor of new onset postepidural FHR abnormalities.

Continuous infusion of 17-hydroxyprogesterone caproate into either the fetoplacental or intervillous circulation of a placental cotyledon attenuates vasoconstriction of the fetoplacental arteries by thromboxane mimetic U46619.

OBJECTIVE The objective of the study was to determine whether pretreatment of fetal or maternal placental vasculature with 17-hydroxyprogesterone caproate (17-P) attenuates the vasoactive effect of the thromboxane mimetic U46619. STUDY DESIGN Two cotyledons were obtained from each placenta studied. For the first 5 placentas, the fetal artery of 1 cotyledon from each pair was infused with 17-P. After 30 minutes, a bolus dose of U46619 was administered to both cotyledons. An identical procedure was carried out on the next 5 placentas except that 17-P was infused into the intervillous space. RESULTS The pressure excursion caused by bolus administration of U46619 was less in the cotyledons infused with 17-P, both in the 5 cases in which the fetal vasculature was infused with 17-P (P = .0035) and in the 5 cases in which the maternal vasculature was infused with 17-P (P = .038). CONCLUSION Pretreatment of either the fetal or maternal circuits of the placenta with 17-P attenuates U46619-mediated fetoplacental vasoconstriction.